Absence Notification Form

Instructions: Supervisors complete and submit this form under the following circumstances:

1) An on-campus or remote employee calls in sick for three days/shifts and is not working (regardless of the reason)
OR
2) An on-campus employee reports they are ill/COVID symptoms for three days and are working remotely as a result

“Employee” includes faculty and staff, student employees, and temporary/casual labor. This form must be submitted within 24 hours of being notified of the third day/shift absence regardless of whether the employee has indicated symptoms are COVID-19 related. Supervisors do not need to discuss/confirm symptoms.
Supervisors will be informed by HR, the Safety Department or the Health Center if any additional information or action is needed.

Name of person completing form:

Employee Information